Nurse Turnover: Causes, Costs, and Ways to Reduce Turnover

Are you feeling like every time you hire a new nurse and get them trained, another one is on their way out? Even worse, your new nursing hire doesn’t stay a couple of months post orientation?

To a degree, some nurse turnover is an unavoidable part of the administration of a healthcare facility, but that doesn't mean alarmingly high rates are inevitable. You can develop and implement strategies to manage and reduce turnover, and you'll do it best by understanding the costs and the causes first.

What is Nurse Turnover?

Research definitions of nurse turnover vary somewhat—often whether to include voluntary or involuntary turnover; however, it generally refers to when a nurse leaves their present job.

The motivations and circumstances for nurse turnover differ and are widely studied. Thanks to the preponderance and breadth of the research efforts on the subject, healthcare facilities can better understand the actual cost of nurse turnover, both financially and in terms of how it affects patient care— learn the causes and then develop strategies to reduce it.

Impacts of High Nurse Turnover on Healthcare Facilities

The threats of high rates of nurse burnout and subsequent turnover in healthcare facilities are real and carry negative potential outcomes. In fact, the nursing workforce is in dire straits. Not only have more than a quarter of a million nurses left the field since 2020, there is also a decline in the clinical preparedness of new nurse graduates.

1. Increasing Staff Workload

The national average number of days a hospital takes to recruit a registered nurse (RN) is 95—up from 87 in 2022—a significant timespan for a facility to manage one or more vacancies.

Nurse turnover inevitably signifies extended periods with reduced nursing staff for a facility, which impacts scheduling and workload as nurse managers scramble to organize sufficient nurses for staffing shifts—often impacting the facility's ability to provide safe nurse-to-patient staffing ratios. An increased workload here or there may be manageable for a nurse, but when it is near-constant for 95 days, the stress stacking up on nurses is immense.

2. Higher Nurse-to-Patient Staffing Ratios

Fueled at least partly by the long-term nursing shortage that continues to challenge health systems and communities, nurse-to-patient staffing ratios remain popular topics of research and have been linked to patient outcomes by many studies. The COVID-19 pandemic exacerbated the delicate situation.

In 2022, an in-depth systematic review published findings after analyzing 27 studies assessing nurse staffing and its association with patient outcomes in various healthcare settings. Authors of the review reported that many studies were at risk of bias, making them "likely to underestimate the effect of higher registered nurse staffing." Their findings concluded there is "little room for doubt" that a causal link exists between registered nurse staffing and patient mortality. Learn more about this topic by reading our blog post, "Safe Nurse Staffing Ratios Improve Care and Reduce Burnout."

3. Declining Patient Care and Outcomes

It is not only patient mortality associated with inadequate nurse staffing. Another broad-scale review published in 2017 analyzed 35 studies on nurse staffing association with patient outcomes in acute care units and found increased patient mortality and increases in medication errors, ulcers, use of restraints, infections, pneumonia, and interventive procedures. To learn some ways to create a safer hospital environment, read our article with four tips to improve hospital safety.

4. Rising Staffing Costs

Consider the investment a facility makes in terms of finances and time in the recruitment and hiring process for an RN. Then, there is facility orientation, onboarding, and on-the-job training—all paid work time as they rely heavily on experienced nurses for support and assistance.

One study released in 2021 found that the cost of RN turnover ranges "from $28,400 to $51,700, causing a hospital to lose $3.6 million to $6.5 million annually."

In the US Surgeon General's Advisory on Healthcare Worker burnout, nurse turnover costs are estimated to reach $9 billion annually for the industry.

Primary Causes of Turnover Among Nurses

There are multiple reasons and motivations for nurse turnover. Although not all of them are negative—retiring, going back to school to level up licensure, achieving a work-life balance, or moving to another city, for example—the alarmingly high rates the industry is experiencing must be mitigated. Meeting any goals of turnover reduction and increasing retention demands an understanding of the leading causes in order to strategize how to counter them.

Staff Burnout From Heavy Workloads

In 2002, just two years before California became the first state to implement—by law—minimum nurse-to-patient staffing ratios, a notable study analyzed hospitals with high nurse-to-patient ratios and found that each additional patient per nurse increased the likelihood of patient death within 30 days by 7%, and an increased likelihood of failure-to-rescue by 7%. Moreover, each additional patient increased nurse burnout by 23% and job dissatisfaction by 15%.

Compensation and Benefits Concerns

While concerns about compensation and benefits are often listed as motivating factors for leaving a nurse job, they often aren’t the primary cause of low job satisfaction. In a meta-analysis on nurse wages and job satisfaction, low wages weren’t the primary driving factor of high turnover—however, they could lead to higher turnover when combined with other factors like high patient-to-nurse ratios.

Autonomy

When nurses feel under-appreciated or unrecognized for their work, the quality of their patient care can often suffer. A review of studies on nurse burnout identified a strong relationship between a nurse’s low control over job tasks and adverse effects, including negative patient experience, poor job performance, and intention to leave. Working with clinicians to provide autonomy can help foster a sense of control. Nevertheless, the most widely talked about cause is healthcare worker burnout.

Facility Type

In 2022, the US Surgeon General released an advisory addressing healthcare worker burnout, reporting that the healthcare workforce has reached "crisis levels" of burnout. The report listed impaired cognitive function, increased risk of heart disease, diabetes, fertility issues, insomnia, depression, anxiety, and increased risk of substance abuse as associated risks for burnout.

Burnout receives a lot of attention, likely because it feels like the most nebulous and insidious of the other usual causes of nurse turnover.

Furthermore, the type of facility also impacted the level of nurse burnout. In one study on factors that are associated with nurse burnout in the U.S., working in a hospital setting was associated with 80% higher odds of burnout as the reason than for nurses working in a clinic setting. This doesn’t mean hospitals are forced to endure high turnover, but instead that the stress of acute care can be a more prevalent factor than for other types of facilities. The good news is that hospitals can still see success from strategies for reducing burnout and preventing turnover, just like any other type of healthcare facility.

Lack of Recognition or Rewards

Compensation, lack of recognition, and under-appreciation are all reasons that seem straightforward and understandable. When a nurse is completely and utterly exhausted emotionally and mentally—countering burnout is a more complex challenge.

However, that doesn't mean developing strategies and solutions to address turnover causes isn't worthwhile or won't have an impact.

5 Strategies to Reduce Turnover Rates for Nursing Staff

Burnout is a result of a multitude of factors that tangle together—some within a facility's control and others not. By acknowledging what is within your control as a nurse leader, you can work on ways to reduce nurse turnover.

One of the first steps is to create an environment that is supportive and safe for nurses and take steps to actively listen to their input, validate their experiences, and make progress toward improvement. Here are a few strategies to consider.

1. Seek Anonymous Feedback from Nursing Staff to Understand Concerns

It is not enough to tell your nursing staff you are open to feedback. You must create the space for them to do so in a way that they feel safe to be honest. Establish a method or create opportunities for them to provide anonymous feedback. Look for commonalities and take steps to address concerns or suggestions, which demonstrates that their feedback matters.

2. Provide Opportunities for Internal Career Advancement

Check your turnover data and determine how often your nursing staff leaves for better opportunities. Is there a program in your facility that encourages employee wellness or growth within your organization? What are your facility hiring practices when advanced positions open up? Do you recruit from within the organization? Are there opportunities for advancement available to them so they don't have to leave to grow their careers?

3. Highlight Clinician Efforts Through Feedback and Recognition Programs

Examine your current workplace practices on staff recognition and nurse happiness. Is there a program or system in place that recognizes staff

Don't stop there. Discuss with your supervisory staff how often they provide feedback to the staff they supervise. How much of it is positive?

When it is negative, is it provided with guidance and learning opportunities? Lead by example, and gather feedback from your supervisory or administrative staff. Are they feeling appreciated and recognized? Do they have the upper-level support and feedback necessary to foster the attitude, work conditions, and culture you want for your nursing staff?

4. Alleviate Workload Pressure with Flexible Staffing Solutions

Examine your nursing staff's workload and prioritize alleviating their burden. Are your nurses working overtime? Are they being denied vacation leave? As previously mentioned, recruitment to fill vacancies takes time, so you need affordable yet qualified short-term staffing solutions to fill the gaps when you have vacancies or call-offs. Nursa allows significant flexibility so you can quickly and efficiently source nursing staff to lighten the workload and lower nurse-to-patient ratios without costly contracts.

5. Conduct Exit Interviews to Identify Recurring Trends

When a nurse leaves, does your HR department conduct an exit interview? Or are the reasons learned via gossip and whatever they mention to someone on the way out? Exit interviews can be uncomfortable, but they provide insight into turnover trends. When one nurse says they are leaving due to underappreciation, you may take it as anecdotal information. However, when—over some time—several leaving nurses mention it, maybe you need to take a look at the work culture.

Effective Patient Care Starts with Your Nurses

Indeed, implementing the suggested retention strategies requires an investment of time and resources. Nevertheless, can you afford not to take steps to understand and address nursing turnover?

Your main takeaway here is that effective patient care starts with your nurses. For more ideas about improving the work culture in your healthcare organization, read "Nurse Retention Tips for Hospitals and Healthcare Facilities."

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